Please bring all completed documents to the first appointment
WABASH COLLEGE COUNSELING CENTER
Crawfordsville, IN 47933
VOLUNTARY CONSENT FOR MENTAL HEALTH SERVICES:
I, the undersigned, agree and consent to the mental health services offered and provided by the Wabash
College Counseling Center.
Wabash College Counseling Center has retained the services of licensed mental health professionals
who provide various mental health services. I understand that I am consenting and agreeing only to
those mental health services that are within the scope of the practitioner’s license, certification and
training.
By signing my name below, I certify that I have read this consent form and agree to all the provisions
contained in it.
By signing my name, I also certify that the practitioner ___ may , or ___ may not (check one) contact
me by e-mail, which is not a confidential form of communication.
_________________________________________
Signature of Client
______________________________________
Signature of Witness
__________________________
Date
________________________
Date
IF the client is a minor, or otherwise incompetent to give consent, complete the following:
___ Client is a minor ( ___ years of age )
___ Client is not a minor, but is unable to give consent because: ______________________________
___________________________________________________________________________________
For and on behalf of the client, I hereby execute the foregoing consent form, and I represent that I am
authorized to do so.
______________________________
Signature of Parent, Guardian or Other
Person Signing for Client
_______________________________
Printed Name of Parent, Guardian or
Person Signing for Client
_____________________________
Signature of Witness
________________
Date
___________________________________
Relationship of Person Signing for Client
Wabash College Counseling Center - Client Rights
 To participate in and to consent to treatment.
 To participate in developing an individual plan of treatment.
 To receive an explanation of services in accordance with the treatment
plan.
 To object to, or terminate, treatment.
 To have records protected by confidentiality and not be revealed to
anyone without client’s written authorization, except where authorized
by Federal and State law.
 To have access to a summary of one’s records.
 To receive clinically appropriate care and treatment that is suited to their
needs or to be directed where such care may be available.
 To be treated in a manner that is ethical and free from abuse,
discrimination, mistreatment, and/or exploitation.
 To be treated by staff who are sensitive to one’s cultural background.
 To be free to report grievances regarding services, or staff, to the Dean of
Students.
 To be informed of expected results of all therapies prescribed, including
their possible adverse effects.
 To request a change in counselor.
8/12
Please bring all completed documents to the first appointment
Wabash College Counseling Center
Crawfordsville, IN 47933
(765) 361-6252
RECEIPT OF NOTICE OF PRIVACY
PRACTICES
I have received the Family Educational Rights and Privacy Act (FERPA) Guidelines for Wabash College.
Client’s Printed Name: _______________________________________________________
Client’s Signature: ___________________________________________________________
Date: _______________________
Witness Signature: __________________________________
Date: ______________________
8/12
.
Family Educational Rights and Privacy Act (FERPA)
Guidelines for
Wabash College
Wabash College
Office of the Registrar
P.O. Box 352
301 W. Wabash
Crawfordsville, IN 47933
765-361-6245
Availability of Student Records and Graduation Rates
The Registrar's Office will not release academic information (transcripts, grade averages, class
rank, etc.) electronically (telephone, fax, or e-mail) to any individual, including the student.
Requests for such information must be submitted in writing bearing the student's signature.
Faxed requests are acceptable provided they bear the student's signature. E-mail requests are
acceptable providing they have a letter bearing the student's handwritten signature attached.
Please allow two working days for processing of information and transcript requests.
Replacement diplomas will NOT be issued in any name other than that certified (on record) at
the time of graduation.
Student Education Records
The Family Educational Rights and Privacy Act (FERPA) provides certain rights with respect to
education records. These rights include:
(1) The right to inspect and review the student's education records within 45 days of the day
the College receives a request for access. A student should submit to the Registrar a written
request that identifies the record(s) to be inspected. The registrar will make arrangements for
access and notify the student of the time and place during regular business hours where the
records may be inspected. A Wabash official will be present during the inspection.
(2) The right to request the amendment of the student’s education records that the student
believes are inaccurate, misleading, or otherwise in violation of the student’s privacy rights
under FERPA. A student who wishes to ask the College to amend a record should write the
College official responsible for the record, clearly identify the part of the record the requester
wants changed, specify why it should be changed, and send a copy of the letter to the Registrar
as well. If the College decides not to amend the record as requested, the College will notify the
student in writing of the decision and the student’s right to a hearing regarding the request for
amendment. Additional information regarding the hearing procedures will be provided to the
student when notified of the right to a hearing.
(3) The right to provide written consent before the College discloses personally identifiable
information from the student's education records, except to the extent that FERPA authorizes
disclosure without consent. FERPA permits the College to release education records to the
parents of a dependent student without the student's prior written consent. A parent must
submit sufficient proof of identity and student dependency before he or she will be permitted
to receive an education record under this exception. The College may also disclose education
records without a student’s prior written consent under the FERPA exception for disclosure to
school officials with legitimate educational interests. A school official is a person employed by
the College in an administrative, supervisory, academic or research, or support staff position
(including security personnel and health staff); a person or company with whom the College has
contracted as its agent to provide a service instead of using College employees or officials (such
as an attorney, auditor, or collection agent); a person serving on the Board of Trustees; or a
student assisting another school official in performing his or her tasks. A school official has a
legitimate educational interest if the official needs to review an education record in order to
fulfill his or her professional responsibilities for the College. Upon request, the College also
discloses education records without the student's written consent to officials of another school
in which a student seeks or intends to enroll. FERPA also permits the College to disclose
without a student's prior written consent appropriately designated "directory information,"
which includes the Wabash student’s name; his local college, home, and cell phone numbers;
local college and home address; e-mail or other electronic messaging address; age; major field
of study; participation in officially recognized activities and sports; class standing; weight and
height of members of athletic teams; honors, awards, and scholarships earned; photographs;
dates of attendance; degree received; post-graduate plans; and most recent previous
educational agency or institution attended. A request that directory information not be
released without prior written consent may be filed in writing with the Registrar two weeks
prior to enrollment. The foregoing list of FERPA exceptions is illustrative and not exclusive;
there are additional FERPA exceptions from the prior written consent requirement. In addition,
the Solomon Amendment requires the College to grant military recruiters access to campus and
to provide them with student recruitment information, which includes student name, address,
telephone listing, age or year of birth, place of birth, level of education or degrees received,
most recent educational institution attended, and current major(s).
(4) The right to file a complaint with the U.S. Department of Education concerning alleged
failures by the College to comply with the requirements of FERPA. The name and address of
the Office that administers FERPA is:
Family Policy Compliance Office
U.S. Department of Education
400 Maryland Avenue, SW
Washington, DC 20202-5901
Please bring all completed documents to the first appointment
WABASH COLLEGE COUNSELING CENTER
CHAPEL – LOWER LEVEL
CRAWFORDSVILLE, IN 47933
Client Information
Client Name: _____________________________________ Age: ______DOB:__________ Date Completed: ___________
Client Type: _____ Student _____Student Dependent _____Other
Class: ______Freshman ______Sophomore
Initial Status:
_____ Request for Counseling
Referral Source: _____ Self- Referral
Gender:
______Junior ______Senior
_____General Information
_____Faculty Referral
Male _____
Female _____
Grad.Year: _____________
_____ Crisis Contact
______ Staff Referral _____ Physician Referral
Referring Person/Program _________________________________________________________
Living Unit: _________________________________________ Recent Change? ___________________________________
Campus Address: ______________________________________________________________________________________
(Street-Route)
(City)
(State)
(Zip)
Home Address: ________________________________________________________________________________________
(Street-Route)
(City)
(State)
(Zip)
Where would you like to receive Confidential Mail ? (check all that apply)
Email _____
Email Address? _________________________________________________________________
(Note: Information sent over the internet may not be able to be protected )
Campus Address _____ Home Address _____
Send No Confidential Mail ______
How can you be reached by phone?
Cell Ph:____________________ ( Note: Conversations over cell networks may not be secure or private)
Campus Ph:_______________________
Home Ph:________________________
Best time to call _______________________________________________________________________________
Additional Authorized Contacts _________________________ Phone# ___________________ Rel. ___________
Please call me at: Cell _____ Campus _____ Home _____ Is it OK to leave a confidential message?  Yes  No
Student Ethnicity/Country of Origin: ______________ Marital Status: _________ How Long:_____ # of children:________
Education: (highest year completed) _____Currently in school?  Yes
 No Major/Degree: ______________________
Current Work (include ESH): _________________________ Time in current position ______ Organization______________
Other Jobs: _______________________________________________________________________Military veteran? ______
What concerns/issues brought you here? Why now? _________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Other possible areas of concern that you may be experiencing (please check all that apply):
_____Family Relationships
_____Marital Relationships
_____School/Academic Issues
_____Problems with Temper or Anger
_____Another’s Alcohol/Drugs
_____Stress
_____Social Relationships
_____Physical/Medical
_____Legal
Other_________________________________________________________________________________________________
______________________________________________________________________________________________________
WABASH COLLEGE COUNSELING CENTER
Client Information Pg 2
Client Name:__________________________________________________
Have you ever seen a professional for counseling? Yes ______ No ______ If yes, who: _________________________
For what? ____________________________________________________________________________________
Are you currently in counseling? Yes ______ No ______ Where/ Last session? __________________________________
Who is your primary care physician?________________ Location? ________________ Phone# __________________
Other specialty care physician? ____________________ Location? ________________ Phone #__________________
Please list all physical conditions you have been treated for in the past? ___________________________________________
_____________________________________________________________________________________________________
Are you a current patient at the Student Health Clinic? Yes ____ No ____ Past patient?
Yes ____ No ____
For what?_____________________________________________________________________________________
Are you presently taking a prescribed medication?
Yes ______
No ______, What: ________________________________________________________________________
_____________________________________________________________________________________________________
Have you taken a prescribed medication in the past? (Include any meds for Anxiety, Depression, Sleep, ADD, etc.)
Yes ______
No ______, What: _________________________________________________________________________
____________________________________________________________________________________________________
Have you used ANY alcohol in the last 6 months? Yes ______
No ______
Last use? _____________________
How often do you have a drink containing alcohol?
_____ Never ____ Monthly or less ____ 2-4 times a month ____ 2-3 times a week ____ 4 or more times a week
How many drinks containing alcohol do you have on a typical day of drinking? _ 1 or 2
_ 3 or 4
_ 5 or 6 _ 7 to 9 _
How often do you have five or more drinks on one occasion?
__
Never __
Less than monthly __ Monthly __ Weekly __
Dailey or almost daily
How do you describe your use of alcohol? __________________________________________________________________
Have you ever used ANY other drug(s) or abused prescription drugs?
Yes ______
No ______
Recently used what drug(s)? _____________________________________________ Last use? ____________________
How often do you use?_____________________________________________ Amount when used? ______________
What drugs have you abused in the past? ____________________________________________________________________
When? ______________________________________________________________________________________
Has your use of alcohol or drugs increased or decreased in the last 6 mo ? Why? _________________________________
_____________________________________________________________________________________________________
Any history of legal charges, job/school consequences, or loss of relationship due to alcohol &/or drugs
Yes ____
No ____
Have you ever received treatment because of your alcohol or drug use?
Yes ______
No ______
Do you or have you ever attended a 12 step meeting or support group?
Yes ______
No ______
Are you significantly concerned about another person’s use of alcohol/drugs? ______________________________________
___________________________________________________________________________________________________
10 +
WABASH COLLEGE COUNSELING CENTER
Client Information Pg 3
Client Name:__________________________________________________
PLEASE ANSWER ALL QUESTIONS
ARE you currently, or HAVE you experienced, any of the following: (Circle correct answer)
 Problems with sleep? Y N
Memory problems? Y N
Appetite < / >? Y N
Crying frequently? Y N
Feeling sad, empty, or hopeless? Y N
Thinking/Concentration/Decision problems? Y N
Loss of interest in daily activities? Y N
Excessive agitation/fatigue? Y N
Significant weight loss or gain? Y N
 Thoughts of harming yourself?
 Thoughts of harming someone else?
Presently? Y N
Presently? Y N
 History of / or currently a victim of physical or sexual abuse?
In the past month? Y N
In the past month? Y N
Yes
No
Explain any yes answer above. Anything further you feel I should know?
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Any/other school or job related issues?
______Lack of concentration
______Absenteeism
______Tardiness
______ Confusion
______Temper
_____Poor quality work
_____ Problem with peers
____Difficulty completing tasks ____ Not turning in assignments ____Problems with faculty ____ Problems with staff
____ Fatigue _____ Excessive school activities _____Problems with coaching staff ______Other______________
_____________________________________________________________________________________________
The following questions are for referral purposes only.
Health Insurance Carrier: ________________________________________________________________________________
Name of Primary Insured _____________________________________________ Primary Insured’s DOB: _____________
Primary’s Address (if different from client)
_______________________________________________________________________________________________
ID # ________________ Grp. #:________________ Phone number for MH/SA Services? __________________
Primary Insured’s company or employer: ___________________________________________________________
This above information is true to the best of my knowledge.
Signed _____________________________________________________________
Date of intake: ____________
Please bring all completed documents to the first appointment